Substance use: An old problem requires new solutions

President Donald Trump has acknowledged that overdose deaths are “a tremendous problem in our country.” In a press briefing on Tuesday, Aug. 8, he stated that this epidemic threatens everybody, “young and old, rich and poor, urban and rural communities.” It would be hard to argue the President’s point of view.

However, many behavioral health professionals and advocates might contest his emphasized solution – ramping up prevention and law enforcement practices. “We can’t jail our way out of this,” said Rahul Gupta, health commissioner for West Virginia, the state with the highest rate of drug overdose deaths in the country.

Conspicuously, treatment was absent among the President’s proposed solutions, in spite of a recommendation by the Commission on Combating Drug Addiction and the Opioid Crisis that the U.S. “rapidly increase treatment capacity.”

“We can’t jail our way out of this,” said Rahul Gupta, health commissioner for West Virginia, the state with the highest rate of drug overdose deaths in the country.

Opioid addiction is an emotional topic, which can lead to emotional conclusions. However, companies like Beacon Health Options have a responsibility to draw from the evidence to develop solutions.

What does the evidence say?

Increased law enforcement. In 1969, President Nixon’s War on Drug’s annual budget was $65 million. Today, that budget is now nearly $20 billion, with two-thirds going to interdiction, eradication and law enforcement, according to Common Sense for Drug Policy (CSDP). However, the drug problem is not getting better. In fact, it’s worse. Adolescent drug use has been on the rise since 1990; overdose deaths have never been higher; emergency room use for drug-related incidents are at record highs; and drugs are getting purer and cheaper. Meanwhile, the FBI reports record drug arrests of 1.6 million people annually; nearly 500,000 are in prison (out of a total prison population of approximately 2.2 million). Put differently, the drug war is successful at law enforcement, yet our country’s drug problem only deepens, according to CSDP.

Prevention. This is an area where the results are mixed and suggest that the term “prevention” can no longer assume business-as-usual solutions. One Rand Corporation study finds that the effect of school-based drug prevention programs is small but valuable because “[these programs] are relatively cheap and because drug use is so costly to society, and not because the programs, even the model ones, eliminate a large proportion of drug use.” Another study originally published in the American Journal of Public Health confirms previous findings that the grandfather of school-based drug prevention programs, D.A.R.E., is “ineffective.” Interestingly, an article in Scientific American suggests why such programs have been unsuccessful: approaches that involve social interaction. i.e., interaction between instructors and students where students learn the social skills to refuse drugs, work better than those programs that employ educational tactics, i.e., D.A.R.E.

What, then, does work?

Most people would likely agree that our drug policy should include some level of law enforcement and prevention efforts. However, a gap in the President’s proposal lies with treatment. How do we treat those people already affected by a substance use disorder (SUD), and those who will inevitably develop one? A ramped-up drug crisis requires ramped-up solutions, including treatment.

Traditionally, SUD treatment has included drug detoxification and rehabilitation (often inpatient), therapy and some medication-assisted treatment (MAT), which involves the use of such drugs as methadone and buprenorphine to treat addiction as a chronic brain disease, as described in Beacon’s white paper, “Confronting the Crisis of Opioid Addiction”. However, only 10 percent of drug treatment facilities provide MAT for opioid use, according to the Commission on Combating Drug Addiction and the Opioid Crisis – in spite of its effectiveness. The National Institute on Drug Abuse asserts that MAT not only reduces opioid use, criminal activity and infectious disease transmission, but it also increases social functioning and treatment adherence.

The challenges are many. Their solutions, like most solutions, can’t be one-dimensional and certainly can’t be business-as-usual. In support of the national emergency declaration recommended by the President’s commission, Beacon and companies like it, providers, advocates and policymakers can, and should, continue on the path forged by the evidence base.

I tend to agree with the President’s view on tackling this problem. There does need to be continued support for those who have abused these drugs, but the main driver needs to be on preventing any initial use through enforcement.

The initial use of opioids 95% of the time comes from primary care physicians and ER docs over prescribing to the patients they see every day. I don’t see law enforcement having any effect on the initial prevention of these drugs being administered and neither do the people that become addicted to them.